Tag Archives: maternal health

We salute the Initiative by Kenya’s First Lady towards improved maternal and child health outcomes in Kenya. Japheth Mati MD

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The “Beyond Zero Campaign” launched on 24 January 2014 under the stewardship of Kenya’s First Lady, Margaret Kenyatta, seeks to improve maternal and child health outcomes in Kenya. Her enthusiasm and commitment to the success of the Initiative, including the pledge to raise funds for it through participation in the forthcoming London Marathon, is completely unprecedented in Kenya’s history. We salute this initiative by the First Lady of Kenya.

The Strategic Framework for the engagement of the First Lady in HIV control and promotion of maternal, newborn and child health in Kenya, which was unveiled on World AIDS Day 2013 focuses on the following five key areas: (i) Accelerating HIV programmes, (ii) Influencing investment in high impact activities to promote maternal and child health and HIV control, (iii) Mobilizing men as clients, partners and agents of change, (iv) Involving communities to address barriers to accessing HIV, maternal and child health services and (v) Providing leadership, accountability and recognition to accelerate the attainment of HIV, maternal and child health targets.

In an earlier post under the title “What’s in the way of achieving improved maternal health in Kenya” it was observed that there is sufficient knowledge of the causes of maternal deaths, and how they can be prevented. It is known which interventions work and which do not. What appears to be the main barrier is the lack of commitment to act; to prioritize reduction of maternal mortality, and to reflect this in resource allocations to the health sector, and to maternal health services, in particular.

The health budgets in most African countries, Kenya included, do not demonstrate that health is rated as a high priority among other national needs. This is often the result of failure by governments to recognise the importance of health in development, so that expenditure on health is not perceived as a critical economic investment alongside spending on education, agriculture or industries. Yet, health is a critical resource, without which investment in all other sectors would go to waste. Further, poor health creates critical barriers to economic production.

Within the health sector, lack of equity in planning and distribution of resources for health results in inequitable access to health care services: Physical access (e.g. distance to the nearest health facility); Affordability (when fees charged for services are unaffordable); Acceptability (where people lack confidence in the services provided and decide not to utilise them). People who are denied access through the above barriers often turn to out-of-pocket expenditures on their health care. Ironically, evidence reveals that the poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care.

From available evidence it is obvious that local and international health goals cannot be achieved without emphasis on equitable expansion of access to basic services for all. Policy makers and planners must begin to accept the existence of, and to act on, the vast inter- and intra-regional health disparities in Kenya. It was the expectation that devolution would create opportunities for better prioritization of needs at the grassroots, and, through better knowledge of community needs, formulate more focused interventions. 

Engaging with communities as envisaged in key area (iv) of the proposed Strategic Framework is indeed a critical focus, considering that proximity to health facilities and services, is no guarantee they will be utilised. For example, there are several areas in Kenya, both rural and urban, where communities will prefer traditional medicine as their first line of health care before modern drugs are sought. There is evidence to show that within certain communities in Kenya, majority of pregnant women will have consulted a mganga (traditional healer) who administered to them herbal preparations and potions to ward off evil spirits, before making their first antenatal clinic visit[1]. These women perceive antenatal care services available at health facilities- dispensaries and health centres, and those provided by TBAs and herbalists, to be complementary, and generally, they seek both types of care interchangeably. This may have negative effects, for example, due to delays in early diagnosis and management of antenatal complications, resulting in poor pregnancy outcomes.

https://africahealth.wordpress.com/2010/10/27/what%E2%80%99s-in-the-way-of-achieving-improved-maternal-health-in-kenya/

Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf


[1]Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf

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Selected case studies of women who were denied enjoyment of ‘right to health’ in Kenya

 

A review of ‘Human Rights Issues in maternal health care in Kenya: Do Kenyan women enjoy the right to maternal health?’ and ‘Barriers to enjoyment of health as a human right in Africa’ provides a useful background to the case studies.

The recently launched report by the Kenya National Commission on Human Rights[i] highlights several incidents and situations where women were denied their right to health care services both because of non-availability of resources and non-affordability of services, as well as misdeeds on the part of health care providers. People living with disabilities (PWDs), in particular, complained of mistreatment, especially delays in getting attended to in health facilities. Most health institutions were not disabled-friendly in terms of infrastructure and means of communication, for example, facilities for sign language or Braille.

A Level 2 Health Facility at Mtwapa, Mombasa County (Picture: J Mati)

Witnesses raised several complaints related to the inefficient referral systems in several health facilities that caused considerable delays in obtaining higher level care, not infrequently resulting in fatal consequences for the women and their babies. This was particularly a serious problem when it came to referral of patients from levels 1 and 2 to appropriate higher level facilities.

In some cases, women in rural areas had to be transported on wheel barrows by family members or on donkey carts. Where hospitals had ambulances, the patients or the relatives were required to pay amounts ranging from KSHs. 500 to KSHs. 3,000 supposedly to fuel the vehicles. In situations where people were unable to pay, patients were denied treatment. In other instances, blood was not readily available in hospital blood banks, or the facilities lacked adequate infrastructure to obtain blood for emergency transfusions.

In Tana River, for example, a woman who developed complications after delivering at a dispensary (level 2) died while waiting to raise funds, through harambee, to fuel a government ambulance to take her to Hola District Hospital. A similar report is given in connection with a maternal death due to lack of transport between Magarini Dispensary and Malindi District Hospital, both in Kilifi County.

In Lamu County, patients who needed to be referred to Coast Provincial Hospital in Mombasa were reportedly required to pay between KSHs. 8,000 and KSHs. 10,000 to fuel the hospital’s ambulance. Where there are no ambulances, as in Wajir and Marsabit District Hospitals families had either to hire expensive taxis or resort to donkeys and camels to transport their sick members.

Witnesses testified that the high cost of hospital delivery, especially the fees charged at level 4 and 5 facilities, was a key hindrance to accessing skilled attendance at delivery. A witness during the inquiry stated thus: ‘Many women deliver at home because they do not have enough money to go to the hospital’.

 Corruption, especially among hospital management staff, was also cited as a barrier to accessing maternal health services. According to witness accounts from Kitale, corruption in health facilities meant that patients ended up paying for drugs and other items that ought to be provided for free. Similarly, bribes were solicited to facilitate earlier scheduling of surgical treatment, as stated by a witness at the Coast: “For one to get an operation done quickly at Coast General Hospital one has to pay bribes or know someone because there are long queues, so I left”.

Mistreatment in health facilities by unkind, cruel, sometimes inebriated hospital staff, who scolded, abused and even beat patients also features prominently in the report. So are delays in getting attended to in health institutions, particularly in the labour ward, where witnesses complained of being neglected during labour, in some cases ending in delivering unattended within the hospital. An example is the case of a woman who waited at the out-patients from 5am to 4pm before being admitted to the labour ward, ending up with a stillborn child. Women complained of being admitted in overcrowded wards and sharing of beds; up to three women with their babies sharing one bed, even when some of them were still bleeding, which exposed them to potential risk of infection, including HIV and Hepatitis B. Detaining of women for non-payment of hospital charges obviously contributes to congestion in hospital wards.

There were complaints of frequent lack of essential medicines, equipment, commodities and supplies in public health facilities resulting in denial of services to the needy. It was common in most public facilities for patients to be asked to purchase medicines, gloves and dressings, besides being referred to private institutions for specialised radiological and ultrasound diagnostic examinations. Essential resources for effective provision of sexual and reproductive health services were lacking in many health facilities. For example, many lacked the drugs needed for post-exposure prophylaxis (PEP) following sexual abuse including rape. The Inquiry established that non-availability of family planning commodities was a fundamental barrier to accessing comprehensive family planning in Kenya, this being illustrated by the frequent stock outs of commodities. There were complaints of frequent shortages of various contraceptives which denied clients a wide choice of family planning methods.

Several witnesses complained of negligent actions by doctors and midwives, for example, forgetting items such as surgical instruments or swabs in a patient’s abdomen; performing procedures such as hysterectomy without prior informed consent; poorly managed labour leading to ruptured uterus, maternal morbidities such as VVF and RVF, intra-uterine foetal death or a mentally handicapped child,. Other examples of negligent actions or omissions were performing episiotomy and failing to repair it, and failure to recognise accidental injury during surgery and failing to repair it immediately. There were women who complained that not enough information was given to them about the various diagnostic and treatment modalities they had been subjected to by health providers. In particular, there was inadequate information given to the patients before and after surgical procedures.

 The Report cites an article published in The Daily Nation Newspaper of 18th January 2011 on a case of maternal death associated with abortion:

“A woman aged 40 years who was held at Murang’a police station for allegedly procuring an abortion died after she developed complications while in the police cells. The Police said the woman was reported to have terminated the pregnancy by swallowing some chemical, and locked her up in a cell at the police station. They said she later developed complications and was being rushed to hospital when she died en route.”

 It can be argued that had the police taken the woman to a health care professional, instead of holding her in remand at the police station, she most likely would have survived. In other words this was a case of preventable death associated with denial of enjoyment of right to health. Yet this was after the promulgation of the Constitution of Kenya 2010 which has relaxed the rigidity on termination of pregnancy that existed previously. Article 26 (4) permits safe abortion if in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law.

What can be learned from the above case studies?

Clearly, they demonstrate that Kenya has yet to address the well known factors and barriers that have over the years sustained the prevailing high rates of maternal and newborn mortality and morbidity. Maternal health services that are inaccessible, non-affordable and of poor quality, have been perpetuated by several serious weaknesses in the health systems- inadequate capacity in terms of human resources and health infrastructure, negligence and malpractices especially among over-worked de-motivated health service providers, and various socio-cultural barriers, among others. Addressing these barriers is a prerequisite to meeting local and international goals and targets including the Vision 2030 and Millennium Development Goals.


[i] A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya

Barriers to enjoyment of health as a human right in Africa

The full enjoyment of the ‘Right to Health’ in most African countries is constrained by several pervasive barriers that are the subject of the current review, which urges that governments urgently adopt human rights based approaches to all health interventions in order to ensure equitable distribution of health resources throughout all sections of communities.

The Concept of Health as a Human Right: Health is a basic need for human existence and survival and as such, it is a right that must be respected, promoted and protected by government and society. The Universal Declaration of Human Rights states that “Everyone has the right to a standard of living adequate for health and well-being of himself and his family”. The concept of health as human right is stated in the Preamble of the World Health Organization’s Charter (1946), and also in the International Covenant on Economic, Social and Cultural Rights (1966). Art. 12 states of health as a human right: “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The Declaration of Alma Ata (WHO, 1978) stated: “Health, which is the state of complete physical and social well-being, and not merely the absence of infirmity, is a fundamental human right…. the attainment of the highest possible level of health is a most important worldwide social goal.” The right to health is fundamental to the physical and mental well-being of all individuals and is a necessary condition for the exercise of other human rights including the pursuit of an adequate standard of living. Indeed health is fundamental to enjoyment of the right to life, and the right to a healthy life is fundamental to all other constitutional guarantees.

Right to Health is a Constitutional Issue Besides the South African Constitution[i], the Constitution of Kenya (2010), which was promulgated in August 2010, is among the most progressive constitutions in Africa. It provides for the right to health care services. Article 43(1)(a) in the chapter on Bill of Rights states that every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care, and in Article 43(2), that a person shall not be denied emergency medical treatment. Further, Article 27(2) guarantees equality and freedom from discrimination, and the full and equal enjoyment of all rights and fundamental freedoms. The Constitution obligates the government to take legislative, policy and other measures to achieve the progressive realization of the rights as guaranteed in the Constitution, including the right to health. The Right to Equality encompasses within itself the right of a poor patient to quality health care, regardless of their ability to pay.

Right to reproductive health care services: The concept of reproductive rights as a fundamental human right was endorsed at the 1994 International Conference of Population and Development in Cairo, Egypt. The constellation of rights, embracing fundamental human rights established by earlier treaties, was reaffirmed at the 1995 Fourth World Conference on Women in Beijing, China, and in various international and regional agreements since, as well as in many national laws. They include the right to decide the number, timing and spacing of children, the right to voluntarily marry and establish a family, and the right to the highest attainable standard of health, among others.

That reproductive rights are central to meeting international development goals was recognized by the UN World Summit of September 2005, which also endorsed the goal of universal access to reproductive health. Reproductive rights are recognized as valuable ends in themselves, and essential to the enjoyment of other fundamental rights. Attaining the goals of sustainable, equitable development requires that individuals are able to exercise control over their sexual and reproductive lives.

Right to reproductive health care services is explicitly recognised in the Constitution of Kenya (2010), just as it is recognized or implied in several international and regional instruments (see above), including the United Nations Millennium Development Goals (2000); the Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006); and the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009).

Barriers to enjoyment of Right to Health

1. General issues

Enjoyment of right to health in Africa, besides the inadequate financing of the health sector (see below), is indirectly constrained by several factors that operate at the regional and national levels, and mostly outside the mandate of the health sector. These include poverty, food insecurity and hunger, persistent violent conflicts and displacement of persons, heavy disease burden especially due to HIV and AIDS, and the pervasive gender-based negative traditions such as early marriage, female circumcision and lack of women’s empowerment all of which have profound effects on reproductive health outcomes.

2. Inadequate Funding to Health sector

Many governments in Africa have yet to recognise the importance of health in the overall national development, and expenditure on health is not adequately perceived as a critical economic investment alongside spending on education, agriculture or industries. Health is a critical resource for development, without which investment in all other sectors would go to waste. Poor health impacts negatively on economic productivity, through loss of labour, and under-performance due to illness. Poor health creates critical barriers to any measures intended to uplift the social wellbeing of poor and disadvantaged communities.

The levels of health budgets in most African countries do not demonstrate that health is rated as a high priority among other national needs. Despite the fact that in 2001 African countries pledged in Abuja, to increase health sector budgetary allocation to 15% of government expenditure, and although they repeated this pledge in Kampala in July 2010, in most countries national budgetary allocations for health remain far below this target. A 2007 report of the Regional Network for Equity in Health in East and Southern Africa (EQUINET)[ii] which looked into the progress made in various Southern and East African countries towards achieving the Abuja target, showed that with few exceptions most of the countries were still lagging far behind this target seven years since the declaration.

In Kenya, for the fiscal year 2010-11 just about 5.5 percent of the total Government expenditure was allocated to the ministries of Medical Services and Public Health and Sanitation. This translates to less than $1 per capita expenditure, against the recommended figure of $34 which WHO recommends for effective implementation of health interventions.

Figure 1: Real gross expenditure to the health sector, compared to overall gross Kenya Government expenditure (2007/08 – 2011/12)[iii]

A concern of particular relevance to achieving MDG5 is the disproportionate allocation within the health budget to reproductive health care services. Africa Union’s Maputo Plan of Action for Universal Access to Comprehensive Sexual and Reproductive Health Services in Africa (2007-2010) recommended an increase in per capita expenditures to about 18-24% of the $34 per capita recognized by the WHO. However, in many countries the allocation remains much below these figures.

At the international level, global assistance for reproductive health including family planning, financing has fallen in all recipient countries. Figure 2 shows that whereas there has been a steady increase in overall assistance for health, the amount focused on reproductive health and family planning has remained more or less unchanged since the year 2000.

Figure 2: Total international assistance to health and allocation to reproductive health care programmes (2000-2009)

Source: The Millennium Development Goals Report 2011

 

3. Lack of Equity in Planning for health and distribution of resources resulting in inequitable Access to Health Care services:

Physical access to services (distance to nearest Health Facility): Health care utilization is known to be greatly negatively impacted by distance to health care facilities and access to means of transportation. A study[iv] in western Kenya which explored the impact of distance on utilisation of sick child services in rural health facilities established that for every 1 km increase in distance of residence from a clinic, the rate of clinic visits decreased by 34% from the previous kilometer. According to the Kenya National Bureau of Statistics[v], on average only 6.4 percent of people in Kenya can reach a health facility within one kilometre of their residence; nearly a half (47.7%) of the people have to travel 5km or further to reach the nearest health facility, with marked regional variations (Table 1).

 

Figure 3: Proportion of community that has to travel 5km or more to the nearest health facility in Kenya

(Source: The Kenya Integrated Household Budget Survey (KIHBS) 2005/06).

For example, the proportion of people who live 5km or further from the nearest health facility ranges from 20% and 29% respectively in Nairobi and Central regions to 60%, 64% and 86% respectively in Coast, Eastern and North Eastern regions. The geographical dimension must be taken into consideration when planning health care interventions, especially when targeting socio-economically disadvantaged groups.

Affordability of services: Big disparities exist between the poor and the better off with respect to access to health care services which explains the wide gaps in health outcomes not only between rich and poor countries, but also between the wealthy and the poor in most countries. Generally, the poor lack access to health care in terms of: availability, affordability, and acceptability. Poor people are denied access to health care: (a) where public health facilities lack essential drugs, supplies and commodities; (b) where people have to travel long distances to reach health facilities, especially where public transport is scarce; (c) when fees charged for services (cost-sharing) are unaffordable, and even if there is official exemption (e.g. for pregnant women and children under five) or waiver of fees, people still end up paying on top, for drugs and transport (out-of-pocket expenditure); and (d) where people lack confidence in the services provided at local public health facilities and decide not to utilise them (e.g. poor quality services or negative provider attitudes).

The poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care. In Kenya, data from the National Health Accounts (NHA) for fiscal year 2001/2002 showed that Kenyan households were financing over half of all health expenditures[vi], clearly justifying a conclusion that ill-health contributes to, and perpetuates, poverty because health costs deplete people’s meagre resources. In addition, there is considerable evidence to suggest that by and large public spending on health tends to benefit the better off more than the poor. Quite often it is the better off who get the most from public health services, especially hospital care. In other words, government’s investment in health services, far from promoting equity, works against it[vii].

FY 2001/2002 National Health Accounts (NHA) estimation in Kenya

Inadequate financing of the health sector and inequitable distribution of resources explain the major gaps and disparities in health indicators in most African countries, which have featured repeatedly in successive surveys such as the Demographic and Health Survey (DHS). It is important to realise that because of the size of the poorest population, countries cannot hope to achieve health-related MDGs without urgent implementation of inclusive policies in the planning of health interventions.

Addressing barriers to enjoyment of right to health

Governments must strive to address the pervasive barriers to enjoyment of right to health (including sexual and reproductive health) by all citizens by implementing human rights based approach to all interventions aimed at improving the health of the community. This will empower people to participate in decision making and health policy development, as well as strengthening their capacity to hold the health managers and providers accountable. Ministries of Health should work out clear strategies that seek to make health services inclusively available and accessible, of good quality, affordable and culturally acceptable. It is particularly important to adopt evidence-based planning which should ensure equitable distribution of health resources throughout all sections of communities.

Governments in Africa urgently need to recognise the importance of health in the overall national development, and support it by making appropriate budgetary allocation to the health sector along other critical economic investments. In addition, the international community also needs to examine their funding policies over the last decade or so, which have resulted in stagnation of financing of reproductive health especially family planning programmes.


[ii] Equinet (2007). Reclaiming the Resources for Health: A regional analysis of equity in health in East and Southern Africa. Fountain Publishers Kampala, Uganda.

[iii] Figures based on gross approved expenditure (2007/8 – 2010/11) and gross estimates (2011/12). Figures indexed to inflation at 2007 CPI.

[iv] Feikin DR, Nguyen LM, Adazu K, et al., The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya. Trop Med Int Health. 2009 Jan;14(1):54-61. Epub 2008 Nov 14. http://www.ncbi.nlm.nih.gov/pubmed/19021892

[v] Kenya National Bureau of Statistics (KIHBS) BASIC REPORT – www.knbs.or.ke/pdf/Basic%20Report%20(Revised%20Edition).pdf

[vi] www.who.int/entity/nha/country/Kenya_NHA%202002.pdf; Adam Leive, Ke Xu. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bulletin of the World Health Organization Volume 86, Number 11, November 2008, 849-856

[vii] Davidson R. Gwatkin (2003) Free Government Health Services: Are They the Best Way to Reach the Poor?

Access to legalised abortion is a key ingredient to improvement of maternal health in Africa

It is worrying to note that while most advocates of improved maternal health are greatly disturbed by the WHO report that rates of induced abortion worldwide remain high worldwide, and especially the finding that in the Africa region almost all (97%) abortions are unsafe, there are others who belittle the significance of these findings, stating: “Ireland, where abortion is banned, has one of the world’s best maternal health records. Legalised abortion does nothing to improve medical care.”

Whilst it may be possible that Ireland has one of the world’s best maternal health records, it is unrealistic to make that the yardstick, and to conclude that African countries, for example, should stick to their strict anti-abortion laws, and by some grace the high rates of unsafe abortion and maternal deaths will reduce. There is a world of difference between the circumstances under which an average Irish woman lives and that of the average African woman. The Irish woman is today enjoying a living standard above the average woman in the British Isles, and can with ease slip across the channel to obtain safe abortion if need be. All these benefits are beyond the reach of the African woman. The truth of the matter is that the high mortality is concentrated among the poor and marginalised. The wealthy women in Africa have easy access to very safe abortion in their countries or abroad, as necessary. To the rich African woman as it is for the Irish, perhaps “legalised abortion does nothing to improve medical care”; to the average woman in Africa, it can be a matter of life and death. Restrictive abortion laws do not translate to lower abortion rates, but unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion.

Lack of concurrence between policy and practice is a serious blow to achievement of MDG5 in Kenya

What holds Kenya back in its efforts to achieve MDG 5 is staring us in the face. We just need to look and see the many areas of non-concurrence between policy and practice, for example, while on the one hand the policy is that of equitable access to RH services, in practice on the other hand, many Kenyans, especially those living in marginalized far-flung areas, have nothing close to equitable access to such RH services. This also applies to the poor irrespective of where they reside.

Among the earlier posts by Africa Health Dialogue there was one entitled “What’s in the way of achieving improved maternal health in Kenya?” in which three key barriers to attainment of improved maternal health in Kenya were discussed: the lack of equity in health planning and implementation; inadequacy of funding to the health sector; and inequitable distribution of resources for health especially financial and human resources.

Since the publication of that post, a lot has changed: first, the urgency of the matter in consideration is much greater now- there is much less time left to 2015; secondly, Kenya now has a Constitution that is specific in its provision of health as a basic right. Article 43 (1) (a) states:  “Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care”. The constitution is not saying that only the urban rich and those living in the more accessible counties have the right to the “highest attainable standard of health”. No, it is all Kenyans, wherever they may be!

In addition, we also have a National Reproductive Health Policy (2007) with its stated goal of enhancing the RH status of all Kenyans by (among others) increasing equitable access to RH services and improving responsiveness to client needs. According to the Policy all pregnant women should have access to skilled care throughout the continuum of pregnancy, childbirth and postnatal periods. Skilled attendance implies access to appropriately trained health providers whether in a health facility or through domiciliary care. It also implies access to a rapid means of referral to a higher level of care in case of an emergency. In consideration of the above, at least three questions immediately arise: (a) to what extent are maternal health services equitable; (b) are the current health interventions responsive to client needs and (c) how accessible is skilled attendance by all pregnant women in Kenya?

Review of maternal health indicators as published in successive national surveys, such as the Kenya Demographic and Health Survey (KDHS) and the Kenya Service Provision Assessment Survey (KSPA), shows that health services are far from being equitably distributed in Kenya. Women from the more marginal areas which are lacking in communication infrastructure, especially roads, and those who are in the lower socio-economic strata, are all grossly disadvantaged. In fact, these are the women who register the worst maternal health indicators (whether it be maternal mortality ratio, contraceptive prevalence rate, total fertility rate, attendance by a skilled health professional; or availability and quality of antenatal and delivery services in local health facilities, etc. etc. Unfortunately, forgetting them is not an option; Kenya will never achieve MDG5 without their contribution! That’s the way it is.

In many parts of Kenya it’s nightmarish ferrying a woman in labour to a health facility.

CASE STUDY: The following narrative is based on a true event which took place in eastern part of Mwingi in the Kitui County:

Kavata was a married mother of three, all normal deliveries at home assisted by a TBA from the neighbourhood. During her fourth pregnancy she had attended an antenatal clinic at a dispensary, beginning from the sixth month. She made a total of three antenatal clinic visits before she went into labour. At the clinic she had been advised that even though her pregnancy was progressing satisfactorily, she needed to ensure that this time round she delivered at a health centre because of her history of heavy bleeding during her last delivery. The health centre, located about 15km from her home, had only one qualified midwife, who also had other duties apart from midwifery.

Kavata went in labour at night but could not get to the health centre at that hour; the only matatu in the area made the trip twice a day, early in the morning and early in the afternoon. Walking at that time was out of the question for fear of marauding wild animals and muggers in the area. So, at 6am next day she was in the matatus heading for the health centre where she arrived at 9am. However, she could not be admitted immediately to the maternity ward because the midwife had not reported to work until 10am.

By 2pm the midwife observing that labour was not progressing normally radioed the District Hospital located about 80km away, requesting for an ambulance to transfer the patient for more specialized care. This was not possible – the only functional land rover at the hospital had travelled to Nairobi to fetch supplies. Now the only transport option available at that time for Kavata was a ride at the back of a lorry, perched on top of cowpea bags. The lorry made several stops collecting more bags on the way. By the time Kavata arrived at the District Hospital her uterus had already ruptured and she had bled profusely. Her baby had already died; she too died before anything could be done to save her life.

The big question is “Was Kavata and the many other women who are continually going her way, also expected to enjoy the “right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care”? Is there concurrence between policy and practice: on the one hand the policy is that of equitable access to RH services, but on the other hand, in practice people like the late Kavata and many others have nothing close to equitable access to such services?

Forgetting Them Is Not An Option

Is it possible to achieve the health related MDGs without a special focus on the health status of the poor, the marginalized and the hard-to reach in Kenya?

The Government of Kenya being signatory to the Millennium Declaration is obliged to put in place measures for achievement of the Millennium Development Goals (MDGs). While only three of the eight MDGs relate directly to health, all others have important direct effects on health considering the interrelationship between health and development in general. The core health MDGs are Reducing Child Mortality (MDG4), Improve Maternal Health (MDG5), and Combat HIV/AIDS, Malaria and other Diseases (MDG6).

Achieving the health related Millennium Development Goals (MDGs) will not be possible without a special focus on the health status of the poor, the marginalized and the hard-to reach in Kenya. This post examines the evidence to support this position utilising findings from the 2008-9 Kenya Demographic and Health Survey (KDHS), with regard to the following selected indicators: Under-five mortality rate (MDG4.1); Percent births attended by skilled attendant (MDG5.2); Contraceptive prevalence rate (MDG5.3); and Unmet need for family planning (MDG5.6).

Analysis of the data on the various health indicators shows vast disparities exist based on socio-economic status and the area of residence (see Table 1). These disparities have persisted in results of successive national surveys over the last three decades. Generally, the national average statistic is used in reports regarding achievement of goals (national or international). However, such data is not particularly useful when it comes to designing interventions to improve on the health indicators, since it fails to direct attention to where greatest need for intervention exists.

Under-5 Mortality Rate (MDG4.1): Nationally there has been significant improvement in child survival in the last decade which could be attributed at least in part to childhood immunization coverage and malaria prevention interventions. However, analysis of the data by region shows there are areas in this country where child mortality rates remain very high. Whereas there was a 28 percent reduction in under-five mortality rate in Nyanza from 206 deaths per 1,000 reported in 2003 to 149 deaths per 1,000 in 2008/9, the region remains the place with the highest child mortality rate in Kenya. Almost one in seven children in Nyanza dies before attaining his or her fifth birthday, compared with one in 20 children in Central province (51 deaths per 1,000), which has the lowest rate. The risk of dying before age five is almost three times higher in Nyanza than in Central province.

The other variables shown in Table 1 which influence child survival are mother’s level of education and household wealth status. Under-five mortality is noticeably lower for children whose mothers either completed primary school (68 deaths per 1,000 live births) or attended secondary school (59 deaths per 1,000 live births) than among those whose mothers have no education (86 deaths per 1,000 live births). However, under-five mortality is highest among children whose mothers have incomplete primary education. Similar patterns are observed for infant mortality levels (not shown). Child mortality rates generally decline as the wealth quintile increases, though the pattern is not uniform.

Skilled attendance at delivery (MDG5.2): The policy of the Ministry of Health as stated in the National Reproductive Health Policy (2007) is that all women should have access to skilled attendance throughout the continuum of pregnancy, childbirth and postpartum periods, and that the Traditional Birth Attendant (TBA) is no longer recognised as a skilled attendant. Overall, the data shows that only 44 percent of births in Kenya are delivered under the supervision of a skilled birth attendant, usually a nurse or midwife, and that TBAs continue to play a vital role in providing delivery services. Almost 28 percent of births were assisted by TBAs, the same percentage as were assisted by nurses and midwives. As expected, births in urban areas and births to mothers who have more education or wealth are more likely to be assisted by medical personnel than are those births to mothers who reside in rural areas or who have less education or wealth. Regional differentials in type of assistance at delivery are also pronounced, with Western province recording the lowest proportion (26 percent) of births assisted by medical professionals, followed by North Eastern province (32 percent). Nairobi has the highest proportion of births assisted by medical personnel (89 percent).

Contraceptive Prevalence Rate (MDG5.3): Married women in urban areas are more likely to use a contraceptive (53 percent) than their rural counterparts (43 percent). Contraceptive use increases dramatically with increasing level of education. Use of any contraceptive methods rises from 20 percent among married women in the lowest wealth quintile to 57 percent among those in the fourth wealth quintile, and then drops off slightly for those in the highest wealth quintile. The North Eastern Province had the lowest CPR of 4 percent.

Unmet need for FP (MDG5.6): Levels of unmet need for family planning remain high among Kenyan women, with nearly a quarter (26%) of currently married women indicating that they have unmet need for family planning. Unmet need for family planning is higher in rural areas (27 percent) than in urban areas (20 percent). Nyanza province has the highest percentage of married women with an unmet need for family planning (32 percent), followed by Rift Valley province (31 percent), while Nairobi, North Eastern, and Central provinces have the lowest unmet need at 15-16 percent. Married women with incomplete primary education have the highest unmet need for family planning (33 percent) compared with those with completed primary education (27 percent), no education (26 percent), and secondary and higher education (17 percent). Unmet need declines steadily as wealth increases, from 38 percent of married women in the lowest quintile to 19 percent of those in the highest quintile.

What we learn from these findings in KDHS is that vast disparities persist according to spatial distribution and socio-economic strata of the populations; this implies that we cannot achieve health related MDGs without bringing on board all including the poor and marginalized groups. Forgetting them is not an option! The GOK needs to openly recognise that achievement of MDGs will remain an illusion so long as current disparities in access to health care persist. There needs to be concordance between policy statements of equity and practice; commensurate allocation according to need. Hopefully the devolved county governments will make use of disaggregated data in their planning and budgetary processes, and ensure equitable access to health care for all.

My considered view on the new Africa based study published in the Lancet linking hormonal contraception for women to increased HIV infection risk

A research report published in the Lancet on 4th October 2011 has provoked widespread fear throughout the world. This multicentre study involving in seven African countries: Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zimbabwe, has shown increased risk of HIV infection to women who used hormonal contraceptives– particularly injectable methods like Depo Provera, as well as to male partners among discordant couples. The global concern is due to the fact that there are more than 140 million women worldwide using hormonal contraceptive methods. In most African countries, Kenya included, the injectable contraceptive is the most widely preferred method. The Kenya Demographic and Health Survey (2008-9) showed that more than a half (22%) of the 39% of Kenyan married women using a modern contraceptive method relied on Depo provera.

Three points are worth emphasizing. First, generally, hormonal contraceptives are safe and effective family planning methods that are central to initiatives to reduce unintended pregnancies, empower women, promote economic development, and improve maternal and child health.  Family planning has a key role to play in the attainment of Millennium Development Goals.

Second, there is no such thing as a contraceptive that is 100% safe and, in fact, contraceptive practice is associated with a variety of risks, depending on the method used. This is why family planning service providers have a responsibility to assess the risk to clients of developing method-associated complications (side effects), depending on the health history and the nature of the method chosen. It is important that all clients seeking family planning services should be assessed with regard to their risk of STIs including HIV/AIDS, remembering that all persons at risk of getting infected with an STI are also at risk of getting infected with HIV. It must be realized that HIV/ AIDS is largely a sexually transmitted disease.

The third point to emphasize is that whereas hormonal contraceptive methods are extremely effective in preventing pregnancy they do not prevent infection with STIs including HIV. On the other hand, proper and consistent use of condoms (male and female) is an effective way of preventing most STIs, including HIV. This is why family planning service providers should promote dual protection- the use of condoms for clients who are at risk of acquiring STIs even when they are using other methods of family planning methods.

In Kenya, the above points are emphasized in the Fourth (2009) Revised Edition of Family Planning Guidelines for Service Providers published by the Division of Reproductive Health, Ministry of Health, which is updated from time to time to incorporate evolving research evidence. It is guided by a WHO Scientific Working Group which periodically reviews the latest scientific information on safety of contraceptive methods, and makes recommendations on criteria for their use in different situations (WHO Medical Eligibility Criteria).

The Status of Maternal Health and Unsafe Abortion in Kenya

Unsafe abortion is a public health concern;

  • In order to achieve MDG 5 on Improving Maternal Health, it is imperative that the issue of unsafe abortions is addressed.
  • Unsafe abortion is an important contributor to the high maternal mortality rates in Kenya
  • Granted unsafe abortion is simply one of several contributors to MMR, BUT it is one we know how to prevent- an important public health principle
  • Incidence of unsafe abortion generally reflects the magnitude of unwanted pregnancies in any particular community.
  • Unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion.

Read more on the  Status of Maternal Health and Unsafe Abortion in Kenya

Is it time for a comprehensive Reproductive Health Act for Kenya?

A Presentation made at the Kenya Medical Association State of Maternal Mortality in Kenya Conference held at the Kenyatta International Conference Centre, Thursday 15th September, 2011

Champions are Urgently Needed for Accelerated Reduction of Maternal Mortality in Africa

“It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for.” Kofi Annan, Former UN Secretary General

Introduction: overcoming resistance to change

There is an urgent need for champions to push for accelerated reduction of the shockingly high maternal death rates in African countries, the general improvement of maternal health in the region, and the attainment of the fifth Millennium Development Goal (MDG5). One of the major challenges for the champions will be overcoming resistance to change. Resistance to change is to be found among all levels of society, among health professionals, including obstetricians and gynaecologists; midwives; medical and nursing training institutions; statutory regulatory bodies; professional societies; health management and administration, as well as political leadership and community in general.

But why is there resistance to change? People fear change, and in medicine there is the familiar tradition of: “We’ve always done it this way.” People harbour doubts as to whether innovations actually work better than the traditional practices. There are legal obstacles, including roles and practices prescribed in laws and regulations. There are limited human, financial and infrastructure resources to sustain application of new practices; and there are socio-cultural factors, gender roles including the status of women in society, that function as barriers to change.

Maternal mortality

Recent assessments of maternal mortality show that across Eastern and Southern Africa, “the most basic and natural act of giving life causes the death of almost 10 women every hour” . In 2008, some 79,000 women died in the region in the process of pregnancy and childbirth, accounting for more than one fifth of all such deaths in the world. According to the 2011 UNICEF Report, the latest estimated figures for maternal mortality ratio in Kenya, Malawi, Uganda and Tanzania are 490, 810, 440 and 580 respectively . These unacceptably high levels of maternal deaths make it extremely doubtful that these countries will succeed in reaching all the indicators of achieving improved maternal health (MDG5) in the next 4 years.

There is need for intensified advocacy, especially towards the recognition of women’s constitutional right to life and health, and therefore their right to quality reproductive health services, which ensure that every pregnancy is wanted; all pregnant women and their infants have access to skilled care; and that every woman is able to reach a functioning health facility to obtain appropriate care in the event of complications. After all, going through pregnancy and childbirth safely is what every woman should expect.

We know that even though complications of pregnancy cannot always be prevented, deaths from these complications can be averted. Up to 75 percent of all maternal deaths can be averted if women received timely and appropriate medical care. Maternal deaths from obstetric complications can be markedly reduced if skilled health personnel and essential supplies, equipment and facilities are available. And yet, apart from Malawi, where 54 percent of births were reported to have been attended by a skilled birth attendant, in the East African countries nearly 60% of all births take place unattended by a skilled attendant. Among the poorest women the majority of birth take place unattended by skilled personnel, the proportions being 72 percent in Uganda, 74 percent in Tanzania, and as high as 80 percent in Kenya .

The direct causes of maternal deaths have long been known, and so are the interventions to prevent them. We know what works and what does not work. Clearly, what is lacking is the commitment, at all levels, to act; to make the reduction of maternal mortality a high priority; and to reflect this in resource allocations to health services, especially for reproductive health services. Professor Mahmoud Fathalla of Egypt once observed that: “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their [women’s] lives are worth saving.” When will our countries decide?

Maternal morbidity

It has been said (though there is want of data) that for every maternal death there are up to thirty times as many cases of pregnancy related illness or disability . The lack of or poor access to, obstetric care is responsible for a major burden of maternal morbidity in African countries. Among such morbidities are the obstetric fistulae, vesico-vaginal fistula (VVF) and/or recto-vaginal fistula (RVF) which are usually the result of neglected obstructed labour.

Let me again illustrate this with the case of one of my patients, by name Halima. During my time in the Department of Obstetrics and Gynaecology at the KNH, in the 1970s, I happened to be one of two gynaecologists with special interest in the treatment of urinary incontinence, the commonest cause of which was VVF. Urinary incontinence is one of the most frightful afflictions of human kind and often results in the sufferer becoming a social outcast. Yet, this condition, which arises mainly from prolonged obstruction of labour during childbirth, is a preventable problem if only all pregnant women had access to skilled care during labour and delivery. At any given time there were one or two such cases in my ward. Halima was one of two teenage girls transferred from the Wajir District Hospital in North-Eastern Kenya, with a very large VVF; almost the entire anterior vaginal wall was missing. We had to repair this defect in stages over several weeks using grafts from other parts of her body. The two girls almost became permanent residents of Ward 23 in the old KNH building, and to occupy them they were provided with knitting kits and encouraged to make whatever they fancied. One morning, as I conducted my ward round Halima presented me with a blue knitted sweater. I was deeply moved by this deed, and for several days pondered over it. I guessed this was her way of expressing gratitude, perhaps for our compassion towards her, because she was, as yet, not cured!

Several lessons can be learned from Halima’s case. Clearly, in terms of addressing her problem, our surgical treatment came at the tail end of a chain of events that resulted in a damage that should never have happened in the first place. Halima was barely 14, too young to be anyone’s wife and to have begun childbearing. She was subjected to the severest type of female circumcision (infibulation), and given off for marriage shortly afterwards. In both situations her human and reproductive rights had been denied; she had been abused by the societal norms she lived under. In fact female genital mutilation (FGM), forced early marriage, and coerced sex were tantamount to gender-based violence. Then when Halima became pregnant she was further denied the right to health care- an opportunity to have access to skilled attendance during the antenatal period, as well as care during childbirth. How sad it is to note that, today, four decades later, many African young women continue to live under conditions that pose as much reproductive risk to their lives and wellbeing as it was for Halima.

Abortion, a fertile ground for change

In Africa, despite the fact that induced abortion takes place among women from all levels of society, the brunt of abortion-related morbidity and mortality is borne almost exclusively by the young and poor women. This perhaps explains the dilatory approach to the prevention of such mortality, where leaders don’t want to take the obvious step towards prevention of unsafe abortion. After all, it does not affect their social class. As such unsafe abortion has continued to be a major contributor to the unacceptably high levels of maternal morbidity and mortality rates that prevail in Africa. It continues to be one of the formidable challenges to the achievement of MDG5 of improving maternal health by 2015.

Yet, it is obvious that stringent abortion laws have not deterred women in need from going through with an abortion; what such laws have achieved is to push many hapless women to undergo unsafe procedures with consequent high rates of morbidity and mortality. For such women, the desire to do away with an unwanted pregnancy can be so intense that they will avail themselves of this last resort despite the law, even the attendant risk to their lives. The procedure of medical termination of pregnancy is simple, short and safe when undertaken in the open, by trained persons; on the other hand clandestine abortion, usually performed by unskilled operators, is expensive, unsafe and life threatening.

The persistence of unsafe abortion in Africa is, ultimately, perpetuated by two key factors: (a) the restrictive laws against termination of pregnancy; and (b) the limited or lack of access to adequate abortion care services. Criminalisation of abortion in majority of African countries is something inherited from the colonial laws, despite the fact that the law has since decriminalised the procedure in the colonial “mother countries” (United Kingdom 1967; France 1975; Italy 1978; Spain 1985; Belgium 1990).

Increasing access to contraception is an effective primary intervention for the prevention of unsafe abortion. However, it is feared that induced abortion may continue being the only means of birth control for many women in some parts of Africa. These are women with very limited access to contraception, who include adolescents and youths who, supposedly on moralistic grounds, are denied not only the services but also information on sexuality.

“Abortion is legal but we just don’t know it”

Sadly, many of the women who suffer unsafe abortion live in countries where abortion is sanctioned under certain conditions, but they are unaware of this provision, or, because of various reasons, they cannot access safe abortion services in their countries. For example, the penal codes in Kenya, Uganda and Tanzania sanction abortion for the preservation of the mother’s life and mental health. The Constitution of Kenya (2010) has recognised legal abortion, even though abortion remains generally restricted in Kenya . It is therefore incumbent upon health care providers to ensure women do have access to what they are legally entitled.

The above notwithstanding, it is regrettable that women continue to go through unsafe abortion even when they qualify for legal termination of pregnancy. In many cases this can be blamed on the health service provider, for example, ignorance of the law, negative attitudes and biases, and conscientious objection to termination of pregnancy; or the lack of appropriate facilities including trained providers. Service providers need to recognise their ethical and legal obligations to provide women in need of abortion with appropriate information on where safe services may be obtained. Medical policies and practices can also serve to restrict access to legal abortion, for example, insistence on unnecessary procedures /practices such hospitalisation. Access to services can also be restricted due to community related factors, especially lack of awareness about the law and facilities that provide legal abortion services.

Conclusion

Clearly, time has come for a paradigm shift in the attitudes of health workers and all others who come in touch with women seeking termination of pregnancy, from the attitude driven by deep-rooted suspicion to one of considerate review of all evidence present in order to ensure women are not denied safe abortion services to which they are legally entitled. The realization of unlimited implementation of existing legal and policy provisions ought to be a key goal of advocacy groups, including the Champions for reproductive rights in Africa.

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